Treatment
algorithms for
divertculitis
„Intestinal disorders“
Budapest, May 2.-3. 2008
Wolfgang Kruis
Ev Krankenhaus Kalk
Universität zu Köln
Germany
Diverticular disease
- pretreatment considerations -
? Acute diverticulitis:
..
Severity ?
uncomplicated
complicated?
? Recurrent diverticulitis: . Structural dammages ?
.
.
Secondary prevention of acute
attacks
Surgery
Diverticular disease
- pretreatment considerations -
? Acute diverticulitis:
..
Severity ?
uncomplicated
complicated?
Severity and different phases of
Diverticulitis
mod. acc. to Hansen & Stock, 1999
Phase I
Phase II
a
b
c
Moderate Severe
Mild
Mild inflammation
Phase III
Peridiverticulitis Penetrating Perforatin
- Phlegmone - Abscess - - Peritonitis -
Acute
Uncomplicated
Recurrent
Complicated
Diverticula of the Colon
5 %*
30 %
70 %
Asymptomatic
Uncomplicated
Diverticular disease
Complications
100% = All subjects with colonic diverticula
•30%: Any Diverticular disease
• * 5% of all subjects with diverticula
Dis Colon Rectum 1989; 32
Dis Colon Rectum 1996; 39
Clinical Gastroenterology 1975; 4
Diverticulosis - Diverticulitis
Divertculitis occurs primarily on the
outer side of the bowel wall
Ergo:
Diagnosis of diverticulitis is made by
cross sectional imaging!
Diverticulum without surrounding
inflammation
Ultrasound
Diverticulum with surrounding
inflammation
CT: Diverticulitis with
abscess formation
Treatment of acute Diverticulitis
with complications
Perforation
Phlegmone / Abscess formation
Not self limited bleeding
Intervention / Surgery
Treatment of acute
Diverticulitis
- uncomplicated mild -
Treatment of acute
Diverticulitis
- uncomplicated mild Outpatient care possible,
Dietary restriction, sufficient fluid replacment,
Analgesics (spasmolytics)
Drugs:
Antibiotics ??
Aminsosalicylates ?
Antibiotics for uncomplicated
Diverticulitis
Retrospective study
n = 311;
Patients with diverticulitis, treated
..
with
antibiotics (n = 193)
without antibiotics (n = 311)
CONCLUSIONS: “Our results indicate that antibiotics are
not mandatory in mild acute diverticulitis. Treatment without
antibiotics appears to be safe and seems not to change the rate
of further events.”
Scand J Gastroenterol 2007;42:41-7
Hjern F, Josephson T, Altman D, Holmström B, Mellgren A, Pollack J, Johansson C.
Division of Surgery, Karolinska Institutet, Stockholm
Mesalamine in painful
Diverticular Disease
(Diverticulitis)
Prospective, randomised (n=123), placebo-controlled; mesalamine pellets 3x1g/d
Mesalamine
Δ pain score (day 28)
45
40
35
days until relief of pain
25
*
30
25
20
15
10
5
0
ITT
PP
* Significant difference
Placebo
% Patients without pain
90
80
*
70
20
60
15
*
10
50
40
30
20
5
10
0
0
ITT
PP
ITT
PP
W Kruis et al, DDW 2007
Treatment of acute
Diverticulitis
- uncomplicated moderate to severe In most patients hospitalisation is recommended,
nothing by mouth, i.v. - therapy
Analgesics (spasmolytics), fluid/electrolyte substitution
Drugs:
Antibiotics
(If necessary interdisciplinary discussion with surgeons)
Diverticular disease
- pretreatment considerations -
Recurrent diverticulitis:
.
.
.
Structural dammages ?
Secondary prevention of acute
attacks
Surgery
Treatment of Diverticulitis
- recurrent Patients` status:
..
.
Structural dammages ?
chronic abscess formation
stenosis
fistulae
As diagnosed by ultrasound and/or CT and/or colonoscopy (stenosis)
Risk factors for development of
complicated Diverticulitis
Immunoincompetence
JD Perkins et al. Am J Surg, 1984
ES Tyau et al. Arch Surg, 1991
Drugs (NSAIDs)
AR Hart et al. Eur J Gastroenterol Hepatol, 2000
Diabetes mellitus
S Hollerbach, 2006
Phenotype: young, fat, male
JA Acosta et al. Am Surg, 1992
J Freischlag et al. Dis Colon Rectum, 1986
PR Schauer et al. Am Jsurg, 1992
Localisation (right-sided)
Y Reismann et al. Int J Colorectal Dis, 1999
Treatment of Diverticulitis
.
- recurrent Structural dammages
and / or
.
Risk factors
Consider elective surgery
Treatment of Diverticulitis
.
- recurrent Without structural dammages
and / or
.
Risk factors
Treatment of recurrent
Diverticulitis
- prevention of acute attacks Secondary prevention of acute attacks - physical activity
- fibre (Plantago)
Drugs:
Cyclical antibiotics
Aminosalicylates (?)
Probiotics ??
Elective surgery (?)
Prevention of divertikulitis
- diets and life style -
Prevention of acute attacks of
recurrent diverticulitis with
cyclical Rifaximin
Global symptom score
C Papi et al Aliment Pharmacol Ther 1995; 9:33-39
Prevention of acute attacks of
recurrent diverticulitis with
Antibiotics +/- Mesalazine
Patients free of symptoms (%)
90
80
***
Rif+Mes
Rif
***
***
70
60
50
***
40
30
20
10
0
3
6
9
n = 218; recurrent divertikulitis
Group combined Rif + Mes:
Rifaximin 400 mg bid
+
7 days
Mesalazine 800 mg bid
Afterwards
Rifaximin 400 mg bid 1 week/
+
month
Mesalazine 800 mg bid
Group Rifaximin:
Rifaximin 400 mg bid 7 days
Afterwards
1 week/
Rifaximin 400 mg bid
month
12 Months
A Tursi et al Digest Liver Dis 2002; 34:510-515
Recurrent Diverticulitis:
Remission after Mesalazine
Probability to remain in remission
1
Mesalazin
Kontrolle
0,9
0,8
0,7
0,6
n = 166
Drop outs n = 44
(12 bec/ complications 7,2% )
p < blinded ??
0,001 randomisied ??
0,5
0,4
0,3
E Trespi et al
Minerva Gastroenterol Dietol
1999; 45:245-252
0,2
0,1
0
12
24
36
Mesalazine 2x400mg/d
7 days
8 Weeks
O-diet
+ antibiotics controls > 30g fibres/d
48
months
48 months
follow-up
Uncomplicated recurrent
Diverticulitis
- elective surgery –
consensus statement
The number of attacks of uncomplicated diverticulitis is not
necessarily an overriding factor in defining the appropriatness of surgery. CT graded severity of a first attack is a predictor of an adverse natural history and may be helpful in
determing the need for surgery.
The Standards Committee of The American Society of Colon and rectal Surgeons
Dis Colon Rectum 2006;49:939-944
Treatment algorithms for
divertculitis
- Summary
Surgery
Diet
0-Diet
iv-therapy/substitut
Analgesics Analgesics
5-ASA
Antibiotics
Mild
Complicated
Surgery
Fibre
Phys activity
Cyclical
antibiotics
5-ASA
Probiotics
Moderate/Severe
Uncomplicated
Acute
-
With
Without
structural dammage/
risk factors
Recurrent
Diverticular disease/Diverticulitis